Retinal Screener

Taking a Look Behind the Screens

A festive message from four very special people...


Merry Christmas everyone!

As a retinal screener, one of the most common complaints I hear from my older patients is that their eyes are watering too much. Particularly when I've had onion soup for lunch, and I'm leaning in close for the eye drops. As a general rule, however, excessive watering in older age is often a sign of dry eye, a revelation which can lead to arguments with certain patients, who insist their eyes are too wet, not too dry. In those cases I tell them it could be keratoconjunctivitis sicca instead.

If I had a pound for every time I've sent a patient to the nearest pharmacy for some lubricating eye drops, I could probably afford to do the MSc in Retinal Screening, but sadly the drops are so cheap, I'd barely make my fortune even if I worked on commission. The fact remains, however, that as retinal screeners, we're probably responsible for the production of more artificial tears than the finalists on The X Factor.

But that could all be about to end. I was taking an eye history from a new patient this week, and he told me that until a couple of years ago he suffered from the most terrible dry eyes, which watered constantly and were frequently sore. But that all changed one day in 2010 when he found an overnight cure.

I'm naturally skeptical of anything patients tell me, including their date of birth and GP, but I took the bait, and asked him what the cure was. He said "Honey". I said "On toast?". He said "No, in my eyes".

My first thought was to consider the possible implications of a patient with diabetes ingesting neat glucose through their eyes. My second thought was to ask "What's next - marmalade for earache?". But having pondered the idea for a moment, I replied that the antibacterial properties of Manuka honey are well established, so I suppose it's not impossible it could have benefits in other areas. The patient shrugged and said "Well I don't use that. I use Tesco's."

Apparently he first heard of the cure in some far-flung land (I think it was the Isle of Wight), and since starting to smear supermarket honey on his eyes two years ago, he's never looked back. Mainly because his eyelids are stuck shut. But his dry eye has completely cleared up, and he now swears by the stuff. Like a trooper.

At the time, I gave his story about as much credence as the lady who once told me her retinal haemorrhages were due to a nurse over-tightening the cuff on her blood pressure monitor, but having done a little research of my own, it appears there could be something in it. The internet is awash with anecdotal (and highly questionable) evidence of the effects of honey on dry eyes, but if you dig around, there are one or two slightly more credible sources.

One comes from the Journal of Apicultural Research, which is the bee all and end all in honey studies, and published a paper in 2007 entitled Using 20% Honey Solution Eye Drops in Patients with Dry Eye Syndrome. Their sample was small at only 36 patients, 19 of whom were given the eye drops, but they reported significant improvement compared with those given artificial tears, and even suggested a positive effect on the state of the cornea in those using honey eye drops.

Another comes from the home of Manuka honey, Australia, and the Institute of Health and Biomedical Innovation at the Queensland University of Technology in Brisbane. They published a study in 2006 which looked at the Effect of Antibacterial Honey on the Ocular Flora in Tear Deficiency and Meibomian Gland Disease. They were cautious not to overstate their results, but the authors' findings were positive enough for them to conclude that "there is sufficient preliminary data to warrant further study of the effects of antibacterial honey in chronic ocular surface diseases".

Fortunately, that 'further study' has been carried out by a bloke from Glasgow, whose findings were published in the indisputable Bible of modern medicine and cutting edge health advice, The Daily Mail. They reported earlier this year that a retired soul DJ who knows a lot about ocular health due to having been shot in the eye with a bow & arrow (I expect there's a tapestry depicting the event in his local pub), had cured his chronic blepharitis with a 99p jar of honey.

Medical proof doesn't get much more watertight than The Daily Mail, so by this point I'm thinking "Ok... so honey cures dry eye and blepharitis. If it can do anything for cataracts, I can solve all our pensioners' problems". I wasn't serious, obviously. But maybe I should have been. After a bit of digging, I found a brief report of a study carried out in Russia in the 1980s, and published in a Russian ophthalmology journal twenty-two years ago, which is entitled Use of Honey in Conservative Treatment of Senile Cataracts. Patients with cataracts were followed for an average of seven years, and whilst 65% of those in the control group got progressively worse, the same was true of only 44% of those given honey eye drops.

That study suggested that honey could halt or slow the progression of cataracts, but another carried out jointly by the University of The Andes in Venezuela and Cardiff University in the UK, goes even further. Published in the Journal of Health Science in 2008, and entitled Putative Anticataract Properties of Honey Studied by the Action of Flavonoids on a Lens Culture Model, the paper suggests that honey could actually reverse the growth of cataracts and produce a reduction in lens opacification.

So that's dry eye, blepharitis and cataracts. At this rate, my patients will have nothing left to complain about. Forget financial backing from Big Pharma, I need to do a sponsorship deal with Gale's.

Back in the good old days, when British Rail were getting there, British Leyland weren't, and the only Diabetic Eye Screening Programme was the moment the star wore sunglasses on The Mary Tyler Moore Show, the thought of having a National Health Service run by private companies seemed about as likely as Gary Glitter being a paedophile.

Obviously a lot has changed since then. Hospitals no longer give out keys to Radio 1 DJs, and numerous NHS services are now delivered by potentially profit-making businesses. Not all services, of course. The complex, high-risk cases that no capitalist would touch with a bargepole are still happily run by the NHS, but the attractive, low-risk services with a good chance of turning a profit, have been kindly taken over by private companies in a benevolent act that gives the British taxpayer greater value for money, whilst maintaining the high standards of care that Nye Bevan dreamt of.

At least that's the theory. I should state immediately that I work for the NHS. But a lot of retinal screeners don't. The National Diabetic Eye Screening Programme includes the likes of Virgin Care in Surrey, Clinicenta in Hertfordshire, Health Intelligence in Suffolk, 1st Retinal Screen in London and Yorkshire, and Medical Imaging UK in Worcestershire, Essex and beyond. As an NHS employee, it's easy to feel like a T-Rex in the last days before the asteroid hit, but is the spread of privatisation in the world of diabetic eye screening necessarily a bad thing?

Well that depends. At the time of writing, entering the word 'Clinicenta' into Google returns seven results on page 1, four of which are negative news stories, including the headline "Patients 'Lost Sight' at NHS Hospital Private Clinic" . So if they're making a profit, they need to spend some of it on PR. But that doesn't make all privatisation (or indeed all Clinicenta services) bad. Assuming that all NHS programmes are run by hard-working, selfless angels, and all private services by ruthless, money-grubbing profiteers is clearly ridiculous.

My only concern would be whether profits are being put before patients. And that might be a common accusation levelled at a private company by supporters of the NHS. What's more worrying is when those private companies themselves accuse the government of awarding contracts based on price rather than standards of care.

Channel 4 broadcast an edition of 'Dispatches' this week entitled 'Getting Rich on the NHS'. Here's a two-minute clip...


Should we shed any tears when one private company is replaced by another? Well, in this case, maybe. 1st Retinal Screen have been providing diabetic eye screening in Swindon and North Wiltshire since the early days of the national programme. And if Mike Nelson is to be believed, they've only recently made any money. The 'sour grapes' accusation is one that's easy to level at Mr Nelson, and to some degree there's probably an element of truth in it. Is it really so outrageous for a new provider to enquire about buying some cameras? One could argue that if you're taking over an existing service and (presumably) employing a lot of the old staff, then making use of their (now redundant) equipment is a logical and sensible step.

But that doesn't make Mike's arguments invalid. When the PCT began the tendering process in February, there were reportedly fourteen expressions of interest from both NHS hospitals and private sector providers. One would assume that 1st Retinal Screen held all the cards in that bidding war, possessing top trumps in experience, knowledge and quality of care. But they lost out on price, which appears to be the one card that consistently trumps all the others. And that has to be a concern.

Virgin Care might end up providing a first rate service, but the initial impact on patients can only be negative. The handover from one company to another inevitably results in a gap in service, which means delays to patients' screening, and a potential for serious consequences. And in the longer term, how can Virgin Care provide a service of similar quality at a price that's 14% lower than 1st Retinal Screen say they need to charge to break even?

Only time will tell. But as a retinal screener, it's a question which worries me. The biggest overhead for any diabetic eye screening programme is its staff, and those staff will inevitably become the focus for any cost-cutting exercise. If losing screeners is not an option, then getting more out of them is the only alternative.

There seems to be a commonly held misconception amongst some NHS screeners that if their programmes are taken over by the likes of Virgin Care, it will mean the replacement of their chronically underfunded facilities with privately-owned state-of-the-art equipment. Clapped-out laptops will be replaced with cutting-edge iPads, stylish new uniforms will be issued, and Richard Branson will be popping in once a week to hand out £50 notes and free air miles. The perception is that NHS poverty will be replaced by Virgin wealth, and we'll all be riding the gravy train to an easy life.

The reality is likely to be the complete opposite. Any company that wins a contract at a rock-bottom price will be looking to squeeze every last penny of value from each of its assets. And that means making staff do a lot more for a lot less. I have no personal experience of working for a private screening company, but common sense tells me that my professional life can only get worse. By definition, my new employer would have outbid my current one on price, and the programme's budget would therefore be even tighter than it is now.

As I understand it, private companies taking over NHS contracts are not allowed to make current staff redundant, meaning that their only option is to get greater value from them. Which means working them harder, with fewer benefits, and less job satisfaction. That might maintain standards of service at first, but how long before an over-worked and dissatisfied screening team begins to impact on patient care?

As taxpayers, we all want value for money from the NHS, but as patients, we want good care too. And as a screener, I'd like to see fairness for staff in the mix also. Undoubtedly there are private companies who can achieve a balance of all three, but for how long? With prices being driven down all the time, something's got to give, and probably already has. It only takes one company to win a contract by lowering standards, and the rest will inevitably follow suit. In the world of business, how else can they compete?

1st Retinal Screen lost the Swindon contract because they couldn't provide a good quality service for a price that low. So what do they do the next time a contract comes up for tender? Lower their standards, or go out of business? It's a choice no company providing NHS services should be forced to make. And the only way to avoid it, is for the government to place less emphasis on price, and more on the quality of patient care. I don't want shareholders getting rich from my NHS care, but I want that care to be decent. And if it's not, then it's time to renationalise.


***UPDATE 7/12/12***
In the above article, I posed the question "Is it really so outrageous for a new provider to enquire about buying some cameras?". Well, I bumped into a chap from 1st Retinal Screen this week, and it seems the answer's yes. Apparently the equipment you own forms a key part of your bid, so if Virgin Care had the cameras they required, why were they keen to buy more? And if they didn't have the necessary equipment, how did they win the contract? Those are questions I'll be asking when I bump into a chap from Virgin Care.

Looking forward to it, Mr Branson...

There have been times over the past few months when I've felt that 'Year 3 of TAT' is so called because some of the images are so poor, they look like they were taken by a class of 7-year-olds. I'm still convinced that one or two were captured by candlelight with the patient's glasses still on, using a pinhole camera knocked up from an old occluder and a box of tropicamide.

I know we're meant to be saving sight, but at times I've been more worried about the vision of the photographer who felt they were acceptable images. We live in an age of digital photography, where the only cost of a bad photo is a few seconds of the operative's time, so surely we should be wiping those smudges off the lens, removing the dust from the microchip, and then bumping up the flash and having another go.

Of course, the whole point of Test and Training is to perform an EQA function, and it's definitely succeeding there. I've identified a few outliers myself, just from looking at the photos. Now we just need to find out which programmes they work for, and teach them how to use a camera.

Personally I think each Test & Training image should be coded to identify the photographer, and come with a scorecard, allowing us all to rate them on a scale of one to ten. Thus every image set would not only give an insight into the skill of the grader, but also provide quality assurance for the photographers. Screeners whose photos receive consistently low marks could be flagged up for more training, in the same way that graders are.

If anything, this is an even more vital aspect of EQA. It's all very well checking that your graders are up to the job, but if the images they're presented with are sub-standard, no amount of grading skill is going to compensate for that, and disease will undoubtedly be missed. The photos are the foundation on which the whole screening process is based, and if programmes make do with poor quality images, that house of cards will soon come crashing down around us.

On the plus side, of course, grading the occasional dodgy photo does give us a bit of practice with the more unusual and challenging images we all face from time to time. So have a go at this one...

Retina Display
Suffice it to say, there's a lot going on there. Fragments of the temporal arcade are still visible, particularly the superior artery, but the optic disc appears to have faded into the background, possibly as a result of papilloedema. The macula is ill-defined, with some haemorrhaging at the fovea, and some lighter patches which could be AMD, hard exudates or clumps of drusen. Overall, the picture looks so ischaemic that virtually the entire retinal blood supply has been shut down, with obvious implications for vision.

It's clearly not a well eye. In fact it's not an eye at all. It's actually a photo of the sun. But I think I'd go for R1M1 and a routine referral.

It's the first of April, which means that from today onwards, local Diabetic Eye Screening Programmes in England will take their first tentative steps down the rocky road to a common pathway. By this time next year, we should all be singing from the same hymn sheet and looking alike. It's as if Jedward are working on a gospel album.

The new national website is already up and running, a new name has been adopted, and issues of 'DES News' are being published online to a potential global readership of just over two billion. Although that's expected to fall when people realise it's not about Des O'Connor. The January edition outlined the changes which will be implemented over the next twelve months to bring screening programmes into line with each other, as well as updating us on the outcome of a recent online consultation which will inform the final decisions on policies.

Those decisions were due to be made in March, and probably have been, but as a humble screener/grader, I'm not privy to such high-level decision-making, and can't be bothered to ask, so I'm still very much in the dark. Which is handy for grading. Despite that position of deep ignorance, I am, however, willing to conduct my own online consultation by inflicting my views on the web, and ruling on those policies myself. I'm like the man from Del Monte. Only less decisive. I think.

One of the hottest potatoes to be chipped away at in the recent online mash-up, is the issue of whether or not to arbitrate between R1/R0. Some of the country's leading ophthalmologists and programme managers have failed to agree on this policy, so it's only fitting that the decision is passed on to a third full-disease grader, who can settle the dispute and make that final decision. So here goes...

The answer's no. In fact, I'll go further. The debate about the benefits, cost-effectiveness, accuracy and outcome of arbitration is a complete red herring. What we should be discussing is not whether to arbitrate between R1/R0, but how screening programmes can eradicate those disagreements in the first place. And that, my friends, is easy. We need to redefine R0.

In my experience, disagreements between R1 and R0 fall into one of two categories:

(i) One grader spots a single microaneurysm. The other grader misses it.
(ii) Both graders spot the same feature, but disagree on whether or not it's retinopathy.

I would suggest that the overwhelming majority of cases fall into the second of those groups. Arbitration grading is not about clear-cut cases of retinopathy or blatant mistakes, it's about agonising over that brownish red dot, and deciding if it's pigment. And that does nobody any favours. Least of all the patient.

One solution might be the use of automated grading to differentiate between R1 and R0, but that has cost implications, and could ultimately lead to the development of Skynet, as depicted in the Terminator films. So it's probably best avoided.

Instead, I propose an entirely new set of grading criteria: The Diabetic Eye Screening Programme's Electronic Rating System. Or DESP E-Rate. Under the DESP E-Rate measures I'm proposing, we would expand the definition of R0 to include anything up to three microanuerysms in one eye. Only when four or more MAs are found to be present, would the grade be raised to R1.

Overnight, this would eradicate the need to arbitrate between R1/R0. There isn't a grader in the country who would miss three microaneurysms in a single eye, and the chances of a patient having as many as four dubious dots are slim to none. Graders might disagree on one or two cases of pigment, but not four in one eye.

The result is that first and second disease graders would instantly be on a common pathway, agreeing on R1/R0 in every single case. In addition, the internal QA function previously provided by arbitrating between R1/R0 would be maintained, because any grader found to have missed more than three MAs in one eye could be sacked on the spot for incompetence.

The lack of disagreements would cause accuracy figures to rise, boosting public confidence in the screening programme, and the simultaneous decrease in retinopathy rates would result in an increase in happiness, a lowering of anxiety and blood pressure, and an overall improvement in the health of the nation. Stress would go down, productivity up, and within five years of adopting these DESP E-Rate measures, UK recession would be a thing of the past.

Admittedly, raising the threshold for R1 would introduce a potential for patients with three MAs in each eye to be given the all-clear, but my question is this: does it make a blind bit of difference? In a quite literal sense. And the answer is no. No one's going to lose their sight over a couple of MAs, and the benefits greatly outweigh the risks.

Take two typical patients: firstly, a twenty-something type 1 with a history of poor control, who has two dozen microaneurysms, a handful of dot haemorrhages, and some exudates outside the macula. And secondly, a newly diagnosed, diet-controlled pensioner, who presents for her first screening appointment with a questionable reddish dot on the nasal view.

Under the old grading criteria, these two patients, who are posterior poles apart in pathology, would receive the same result. Under the DESP E-Rate system, an important distinction would be made. It's about accepting that a hazy red dot, viewed through a slight cataract in the eye of an octogenarian, does not constitute retinopathy.

We're all familiar with the term 'Clinically Significant Macular Oedema', so why not extend that concept to R1? Why not agree that a lone microaneurysm is not clinically significant, and can be safely ignored. If the patient comes back with four, then we'll talk. But in the meantime, we can pull those graders off the arbitration list, and get back to saving sight.

One of the great joys of retinal screening is the relationship you develop with each patient. It might only last for twenty minutes, but by today's standards that's verging on a long-term commitment, so as it's Valentine's Day, I thought I'd share the love by passing on a true story which was told to me by a friend and colleague from another screening programme.

Obviously it's rude to reveal a lady's age, so I can't tell you that she's 52, but what I can tell you is that in addition to being a fine retinal screener, she has the figure of a woman half her age, and resembles a young Julia Roberts. At least in her own mind. To those around her, the phrase 'drop dead gorgeous' refers more to her risk of dying from a heart attack, but either way, she's a respected member of the screening team, and much-loved by patients and colleagues alike. Or so she tells me.

Interestingly, however, whilst being a well-rounded human being in more ways than one, the weight of this mystery screener is distributed mostly around her middle. She might have the spare tyre of a minibus, but she has the elegant wrists and pert bosom of a twenty-one-year-old. And I don't mean Adele.

Personally I'm inclined to believe that all retinal screeners should be a few pounds overweight. I think it shows solidarity with the patients. Let's face it, you can't empathise effectively with a type 2 diabetic unless you've struggled with cake yourself. It gives you a more personal connection and makes you less judgemental. The patients see themselves in you, and feel you're one of them, facing the same challenges in life and going through a similar experience.

Unfortunately that can sometimes lead to problems. Frankly you don't want the patients thinking you're too much like them...

So this friend of mine was doing a screening clinic, and one of her patients was a lady in her forties, who arrived with a child of about four. When it came to putting in the eye drops, the patient said "This is my second time with the drops. I was ok last year, but this time I know what's coming..."

Being an empathic person with a strong sense of sisterhood, my colleague replied "Yes, it's a bit like childbirth - the first time you're naïve and have no idea what's coming. The second time - oh s***, you do!"

You'll have to excuse the language. In the rough and tumble of a screening clinic, people don't always choose the right words. I know a patient who once referred to his bifocals as bisexuals. I'm not here to judge.

Anyway, there are various responses you might expect to that analogy from my colleague, but the one she got was a little unexpected. The patient replied with these four little words:

"Is this your first?"

My friend might be well-fed and fifty, but the patient presumed she was pregnant. It was something of a body blow, but with all that padding around her middle, she didn't feel it. She did, however, set the record straight immediately by responding "Gosh, I've got grown up children!", which was the perfect comeback. Except that it didn't contain the words 'I'm not pregnant'.

The patient, who was still under the impression that she'd met her eye screening soulmate, replied "Me too. I have twenty-year-old twins". And with that, she went back to the waiting room.

Naturally my colleague hoped that was the end of the story, but sadly for her, it wasn't. When the patient returned for the photographs, she sat down at the camera with her four-year-old child, and said "So you're like me - starting again. How long have you got to go?"

It was at this point that my friend knew she was in trouble. In front of her was a well-meaning patient showing a genuine interest in her non-existent baby. By responding "I'm not pregnant, I'm fat", she would risk embarrassing the lady to such an extent that she could be mortified beyond belief and might never return to screening. What was needed was a way of letting the lady down gently, in a caring, considerate, perhaps light-hearted manner which would absolve her of any guilt and embarrassment, and allow them both to move on with the screening appointment without any feelings of awkwardness. It's one of those delicate situations where the screener needs to choose her words carefully in order to extricate herself from an extremely sticky situation, whilst maintaining her self-respect, her dignity and above all, her professionalism.

So she considered the question for a moment, and said this:

"Three months."

At which point the patient wished her good luck for the birth, and settled down for the photos.

That might sound like the end of the story, but of course it's anything but. The patient's on an annual rescreen, so she'll be back next year expecting a blow-by-blow account of the labour. My friend has twelve months to lose weight and fake some baby photos, otherwise she'll have to look the lady in the eye and tell her that motherhood's so great the second time around, she's already expecting another.

This is the VA chart we use in the screening room at one of our hospitals...

That Sinking Feeling
I was using it this morning to test the vision of an older patient, who started reading confidently at the top, only to stop abruptly after 'X-U-A'.

When she failed to continue, I asked her "Can you see anything below that?"

She replied "Yes."

I said "What?"

She said "A sink."

The same word accurately describes what my heart did. I wouldn't mind, but she was deadly serious.

About this blog

I'm a Retinal Screener and Grader currently working for the NHS as part of a Diabetic Retinopathy Screening Programme somewhere in England.
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